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Now the proposed criteria are out, but the link did not work for gender identity disorders or dissociative disorders, although this is the last day for comments. The PTSD criteria were present and I had the following critiques which I posted there.

There are no plans to do a field trial to compare prevalence of PTSD under the new criteria compared to DSM-IV-TR. We will unleash a diagnostic classification system with no idea about the impact it will make on diagnosis. This will increase overnight the number of people who meet criteria for the disorder, with the associated stigma and risk of adverse effects of treatment. The new “Criteria A” expands the number exposed from half the population to probably all of the population (although we don’t know for sure, as there are no studies). Anyone who has witnessed death or threatened death, or threatened sexual violation, or heard about it from a close friend or relative, or heard about aversive details. It doesn’t matter how they reacted, as the stipulation “associated with intense fear, horror or helplessness” has been removed. Some symptoms like “I’ve lost my soul forever” are grounded in JudeoChristian beliefs (this last one makes me wonder if the lights are on in there).
Did you know that you don’t have to use the DSM or buy it? Yep. All you need is the ICD-9 codes for insurance or billing purposes.That’s the APA’s dirty little secret.

Here are the proposed criteria for PTSD

Posttraumatic Stress Disorder*

A. The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways:**

1.Experiencing the event(s) him/herself2.Witnessing the event(s) as they occurred to others
3.Learning that the event(s) occurred to a close relative or close friend
4.Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse)NOTE: Witnessing or exposure to aversive details does not include events that are witnessed only in electronic media, television, movies or pictures, unless this is part of a person’s vocational role. Exposure to aversive details of death applies only to unnatural death.

B. Intrusion symptoms that are associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by 1 or more of the following:

1.Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2.Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). Note: In children, there may be frightening dreams without recognizable content. ***
3.Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4.Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
5.Marked physiological reactions to reminders of the traumatic event(s)
C. Persistent avoidance of stimuli associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by efforts to avoid 1 or more of the following:

1.Thoughts, feelings, or physical sensations that arouse recollections of the traumatic event(s)
2.Activities, places, physical reminders, or times (e.g., anniversary reactions) that arouse recollections of the traumatic event(s)
3.People, conversations, or interpersonal situations that arouse recollections of the traumatic event(s)
D. Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: Note: In children, as evidenced by 2 or more of the following:****

1.Inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia; not due to head injury, alcohol, or drugs).
2.Persistent and exaggerated negative expectations about one’s self, others, or the world (e.g., “I am bad,” “no one can be trusted,” “I’ve lost my soul forever,” “my whole nervous system is permanently ruined,” “the world is completely dangerous”).
3.Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s)
4.Pervasive negative emotional state — for example: fear, horror, anger, guilt, or shame
5.Markedly diminished interest or participation in significant activities.
6.Feeling of detachment or estrangement from others.
7.Persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)
E. Alterations in arousal and reactivity that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: Note: In children, as evidenced by 2 or more of the following:****

1.Irritable, angry, or aggressive behavior2.Reckless or self-destructive behavior
3.Hypervigilance
4.Exaggerated startle response
5.Problems with concentration
6.Sleep disturbance — for example, difficulty falling or staying asleep, or restless sleep.
F. Duration of the disturbance (symptoms in Criteria B, C, D and E) is more than one month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With Delayed Onset: if diagnostic threshold is not exceeded until 6 months or more after the event(s) (although onset of some symptoms may occur sooner than this).

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165

The behavior of the committee members has gotten pretty mean and nasty, and the DSM Anxiety Disorders, OCD, PTSD and Dissociative Disorders committee retaliated against me for writing about the DSM here. I mean, those dudes are pretty thin skinned. And what would you think about a bunch of guys that signs a confidentiality agreement before they even know what they are getting into? Now David Kupfer is herding them toward a deadline of 2010 for completion of the DSM-5 and many are starting to balk. Are they headed toward a precipice?

Background David Kupfer. Forground DSM-5 AD Committee: back row, L to R, Robert Pynoos, Roberto Lewis Hernandez, Gavin Andrews, Katharine Phillips, Matthew Friedman, Scott Rauch, Dan Stein. Front row, L to R, Eric Hollander, Michelle Craske, Murray Stein, Susan Bogels, Hans Ulrich Wittchen, David Spiegel, Robert Ursano

Nice group shot guys! Baaaa!!!

Almost a third of the committee is from foreign countries, which my guess is that they had to go abroad to find people who actually wrote papers but weren’t up to their necks in consulting arrangements with pharmaceutical companies. Part of the attempt to add credibility which seems to characterize this process, like telling members not to consult during the process of working on the DSM.

This week things are fraying more around the cracks. Dr Jane Costello from Duke University resigned from the Workgroup on Children’s and Adolescent Disorders; the reasons outlined in the letter include an overly hasty rush to change things when there is little scientific evidence to support the changes. Hmmm I wonder where I have heard that before? Dan Carlat MD reports on Armegeddon and the developments and on a letter from Robert Spitzer MD and Allen Frances MD to the American Psychiatric Association (APA) Board of Trustees warning of “disastrous unintended consequences” and asking for an outside review panel.

The problem is that the APA is a million or two dollars in debt, and has become addicted to having these new DSM books come out, because then everyone has to throw out the old one and buy the new one, and since they are the publisher they get the profit. With the pipeline of psychiatric drugs drying up there is less advertising from the pharmaceutical industry for their journals and meetings, therefore things are getting tight, and hence the pressure to hurry up the process. However I don’t think that generating income for the APA is a good reason to change diagnostic criteria for mental disorders, and their behavior is going to call into question their rights to do that. Not all psychiatrists (including me) are members of the APA, and there are many other mental health professionals who must live with the DSM.

Anyhoo back to internet addiction disorder, which I guess we should call IAD, it is of course compulsive use of the internet, with hourse spent trolling on line, with disruption of work and social life.

You can read an editorial advocating for its inclusion here.

It is considered to be a big problem in many Asian countries. The other side of this is people who get into Real-life or other online games like that and develop relationships where they start having sex with other peoples avators and then they get caught and kicked out of the house.

I have a treatment for my 12 year olds computer game addiction. It is…

…GET OFF THE COMPUTER!!!

Seriously if anyone wants to know my opinion about IAD, it is that I agree with Allen Frances MD head of DSM-4 that we should shun any new and suspicious looking psychiatric diagnoses as we don’t want to add to the throngs of people who feel like they have been labelled with a psychiatric diagnosis. My opinion is that the DSM process should be put on hold, that the text can be revised but diagnostic criteria should not be revamped until there has been the time to collect more data.

Cheers!

I recently wrote about the editorial by Allen Frances MD, head of DSM-4, criticizing the current process of DSM-5, and now there is a nasty response from the DSM-5 group, authored by Alan Schatzberg MD, James Scully MD, David Kupfer MD, and David Regier MD, that psychiatry blogger Daniel Carlat MD offered to edit for them to make it more respectful. Lol. A blogger offering to help the leaders of academic psychiatry tone down their language. Lol again.

I mean the damn editorial hasn’t even been published yet.

In their response to Frances Kupfer et al make dubious claims that “attorneys” had advised them to have committee members sign confidentiality agreements to protect “intellectual property”. They also charge Frances (as well as Robert Spitzer MD, who founded DSM and has been making the email rounds with criticism of the current process) with greed in wanting to retain royalties from a book he wrote about DSM-4 which would become outdated after the release of DSM-5. I mean anyone in the business knows that book royalties pale in comparison to the hundreds of thousands of dollars to be had doing pharmaceutical industry consulting and speaking. In fact one could even argue that doing things like editing books (which have essentially no revenue, because hardly anyone buys them) is a feather in the cap that helps you get those more lucrative gigs.

One of the diagnoses on the table is Female Sexual Dysfunction (FSD), a “disease” that if accepted would surely drive the drug companies to “identify and treat” these poor lassies with drugs like the testosterone patch (see “Wow A Drug To Have Sex Once More a Month? Sign Me Up!“) or Viagra or whatever psychotropic they could drug out of the medicine cabinet.

Turns out the medicalizing women’s sexuality may not be such a good idea. There is a long and jaded history of evil meddling by medical doctors in this area. The publication of the book Feminine Forever, whose thesis was that post-menopausal women become shriveled asexual crones due to an estrogen deficiency led doctors to put an entire generation of post-menopausal women on hormone replacement therapy (HRT), which in turn was later found to have caused tens of thousands of deaths from heart attack and other problems.

Then there were Masters & Johnson, the famous sex research team who concluded that women had more frequent orgasms than men.

Masters & Johnson on Meet the Press

This “research” however was based on looking through peep holes at brothels, and later their “research sessions” they conducted with each other. Virginia Johnson was Dr. William Masters secretary, and they “partnered” to have sex on a nightly basis for “research” purposes for years. Their report on 67 patients with unwanted homosexuality showing a 70% conversion to heterosexuality using “conversion therapy” was later disclosed as a fraud when noone could find any evidence of the patients. This bizarre “research team” should hardly be taken seriously about women’s orgasms.

Turns out that the DSM-4 has ‘Female Hypoactive Sexual Desire Disorder’ and ‘Female Hypo Orgasmic Disorder’ (I mean did the guy try going down on her?) as well as Dyspaerunia (painful sex). As a recent editorial pointed out, maybe the 43% of women with some type of so-called sexual dysfunction are acting “appropriately”.

I mean, maybe they’re with jerks and don’t feel like doing it?

The American Journal of Psychiatry has been soliciting editorials on the DSM-5 process. Too bad they rejected the editorial by Robert Spitzer MD who founded the DSM, and for FSD they have only this lame piece by a trio of MDs whose pharma disclosures read like a phone book. Lol. Sort of.

Ray Moynihan had a good piece in bmj on FSD (“FSD: The Making of a Disease”) in which he outlines how industry has moved in a serious way to pour cash in the “research and education” of this newly minted disorder, the rife conflicts of interest in the field, and the attempt by drug companies to medicalize female sexuality.

The cause? A comment posted anonymously on his blog stating that Alan Schatzberg, MD, had pressured the DSM committee to loosen the guidelines for psychotic depression so that there would be an expanded market for the medication for depression he developed, mifepristone. Dr. Schatzberg was in the news last year because he had an NIH grant to study the drug but also was revealed to be the owner of four million dollars worth of stock in Corcept, a company that he co-founded and that makes the drug. Dr Schatzberg has since stepped down as Chair of the Department of Psychiatry at Stanford, source of the complaint against me that, yes, I had brought up two of the member of the DSM Anxiety Committee in the context that they were from Brown and Dartmouth, departments that were also sites of financial disclosure issues, so add to that my own university (which cannot be named), we pretty much have brought the circle to completion for the universities involved in last year’s financial disclosure broo ha ha. Also last week the CL Psych blog noted that Dr. Schatzberg in his speech accepting the Presidency of the APA stated that:

…some of the detractors in the press have voiced concern that some folks have earned too good a living, often by doing presentations…I have heard from colleagues and directly from one reporter asking me about one of my colleagues having too high an annual income…our members and residents have never taken vows of poverty…We need to ask ourselves how we have contributed to our own devaluation with which others seem to resonate, and we need to reverse the course. The rewards for our dedication should not be limited to a sense of pride, but we are also entitled to be paid commensurate to the challenge…

It doesn’t seem to me that Dr. Schatzberg has gotten the point that the American public is fed up with academic physicians been paid large sums of money from private industry and using their academic positions to promote their own and their industry partners financial advantages, especially if it impacts on patients. But there hasn’t been a lot of soul searching in psychiatry these days. I guess they’d rather spend their time getting people like me to shut up.

An interesting Anonymous followup comment to Dr. Carlat’s posting I was talking about earlier said that he shouldn’t wonder that people didn’t want him on their committees as he might use things he learns about in secret as “fodder” for his blog which he described as highly read. He also said you “can’t have your cake and eat it to.” Wa-aa? You mean if you want to be honest and transparent that you can’t serve on one of the APA committees? I guess because by implication they are corrupt and operate like the mafia? Hmmm, gonna go have some cake and think about that one…

Lolcat CAN have his cake and eat it too!

This new article by Allen Frances, MD, who chaired the DSM-4 committee, criticizes the secretive approach by the current DSM-5 chair David Kupfer MD, who has insisted on secrecy, no note taking, confidentially agreements, and now I would add bullying of psychiatrists like myself who offer outside commentary. Dr. Kupfer has built up the Department of Psychiatry at the University of Pittsburgh into a research machine through developing the infrastructure of administrative personnel who help with the process of writing and submitting research grant applications for funding by the National Institute of Health (NIH). He is said to call out a “priority score” whenever he hears someone present research. Grants coming from Pittsburgh have the reputation of being technically excellent but not always exciting. It seems like he has brought this mass war enterprise approach to the DSM.

David Kupfer, MD, Chair of the DSM-5 Committee

All of this has gotten me reflecting on academic freedom. I mean, have not one but three organizations telling me to shut up (not counting the people in my personal life): the VA, my university (that which cannot be named here) and academic psychiatry. To whit, I am supposed to get approval to talk to the press from my local VA PR guy, but what this amounts to is that when I get contacted about something that they care about (i.e., Iraq), they shelve it and never get back to me. I mean, if you don’t think that pointing a gun at someone, pulling the trigger, and killing them can’t wreck your marriage or make you suicidal, that’s not my problem, so I don’t really get excited about getting censored about that stuff.

The current behavior of academic psychiatry in the DSM process is more troubling. By stiffling debate and creating a corporate type approach they are going against the very principles of science and academic freedom. One can only conclude that they feel insecure about the validity of their deliberations.

I also get upset about what I feel is my university treating me like an employee of a corporation rather than a professor in a university. I mean they should be glad to have their name associated with this blog when contrasted with other situations in which their name was associated with more questionable practices and they never said anything about it. For shame. And there are other professor bloggers who are much more lippy than I am and they list their universities on their blogs.

There are numerous examples of where a failure of academic freedom for exchange of ideas has had disastrous consequences, e.g. 30 million die in China applying Lisenko’s bogus scientific theories to agriculture which results in mass famine. In fact there is an organization dedicated to academic freedom. This is from wikipedia.

AFAF (Academics For Academic Freedom) [3] is a campaign for lecturers, academic staff and researchers who want to make a public statement in favour of free enquiry and free expression. Their statement of Academic Freedom has two main principles:

1. that academics, both inside and outside the classroom, have unrestricted liberty to question and test received wisdom and to put forward controversial and unpopular opinions, whether or not these are deemed offensive, and
2. that academic institutions have no right to curb the exercise of this freedom by members of their staff, or to use it as grounds for disciplinary action or dismissal.’

AFAF and those who are part of the campaign believe that it is important for academics to be able to express their opinions – not just full stop, but to put them to scrutiny and to open further debate. They are against the idea of telling the public Platonic ‘noble lies’ and believe that people should not be protected from radical views.

Well said.

The work on DSM-5 has, so far, displayed an unhappy combination of soaring ambition and remarkably weak methodology.

He then goes on to explode the statements by Kupfer that the DSM-5 will lead to a “paradigm shift” in psychiatry, which he describes as an “absurd statement” based on the fact that there still is not a single lab test for diagnosis, and the gains are small and incremental in descriptive research. In the absence of evidence, changes in diagnostic criteria are arbitrary and often driven by a single strong member of the sub-committees. Furthermore, the incorporation of sub-threshold diagnoses as official psychiatric diagnoses will be a “bonanza” for drug companies who will expand their markets to new legions of the “newly” mentally ill and rush to “educate” doctors about the new criteria, which they will use to expand drug usage. It will also serve to expand stigma. The cost to research of having to re-do studies because the diagnosis has changed, or unintended consequences of diagnostic changes, are good arguments for his point that one should do as little as possible to change things. 

Dr. Kupfer, however, was quoted as saying “There are no constraints on the degree of change.” Instead of being conservative and guarding against new and goofy diagnoses, they are letting the barn doors fly open. To whit, prodromal syndromes like “pre-psychotic” or at risk for mood disorder are being considered as diagnoses, which will create a whole group of “non-patient patients” who will be forever labeled even if they never develop the disorder. Also behavioral impulses like excess of food, sex, internet, or whatever are up for grabs as diagnoses. That will take something that is a moral problem and turn it into a medical disorder. Dr. Frances writes:

Getting as much outside opinion as possible is crucial to smoking out and avoiding unforeseen problems. We believed that the more eyes and minds that were engaged at all stages of DSM-IV, the fewer the errors we would make. In contrast, DSM-V has had an inexplicably closed and secretive process. Communication to and from the field has been highly restricted. Indeed, even the slight recent increase in openness about DSM-V was forced on to an unwilling leadership only after a series of embarrassing articles appeared in the public press. It is completely ludicrous that the DSM-V Workgroup members had to sign confidentiality agreements that prevent the kind of free discussion that brings to light otherwise hidden problems. DSM-V has also chosen to have relatively few and highly selected advisors. It appears that it will have no Options Book to allow wide scrutiny and contributions from the field.

The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process…

I have decided to write this commentary now only because time is beginning to run out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them. What is needed now is a profound mid-term correction toward greater openness, conservatism, and methodological rigor. I would thus suggest that the trustees of the American Psychiatric Association establish an external review committee to study the progress of the current work on DSM-V and make recommendations for its future direction.

Pretty strong language.

Add to Dr. Kupfer’s strategy of: 1) keep everything a secret; 2) make members sign confidentiality agreements; 3) allow no note taking; 4) ignore outside experts and comments; we can now add, 5) intimidate and ostracize academic psychiatrists whom you can’t ignore.

Readers know I have been writing about the DSM Shadow Team to keep track of the goings ons of the “real” DSM. Well apparently a post I wrote about a proposed Developmental Trauma Disorder in children really ticked them off, as I got an email from someone on the DSM Anxiety, OCD, PTSD and Dissociative Disorders committee whom I thought was a ”friend” un-inviting me to be an author on a paper about another topic (that was after I had already spent several days working on the paper). My crime? Stating that two of the committee members were from Brown and Dartmouth, where psychiatrist colleagues of theirs had gotten caught up in financial misconduct allegations. And one of them tried to kill himself. Seems like a lot of academic psychiatrists are doing that these days.

I have people point out to me all the time the fact that I come from a psychiatry department which has financial disclosure problems, like this one at Gooznews, and they usually make no effort to avert any implications about it, but I stand up and take it like a man.

The other thing that gets me is that the paper I was “invited” to co-author was a response to (drumroll) another one written by some psychologists on the relationship between dissociation and trauma and that I was invited because (drumroll) I had written a post about the paper critiquing it in my own unique and photo-shoppy way. Fact is I got an email from one of the psychologist authors of the paper calling me puerile and stating that he was embarassed to be from the same university… but inviting me to write a response for the journal… which I am doing now… hemph. I mean psychologists can get pissed but still debate… as for psychiatrists… well.

What was particularly chilling about this episode is that the email was copied to all the members of the committee, implying that I was now persona non grata and should be shunned by what are in fact my peers in the anxiety disorders and trauma community of academic psychiatry. I was debating whether to talk about this here but to take this “hit” in silence just re-inforces the mafia type atmosphere of bullying and intimidation that rules the day in academic psychiatry. This lack of transparency and honesty and abuse of power has led to the dreadful situation which academic psychiatry is in today, where they are universally despised by try and play it off as the evil machinations of scientology and other conspiracy theories. I, for one, however, am not going to play along with that game anymore.

Who knows, they may have been behind the anonymous letters sent to the Dean of my university complaining about another post that led them to ask that my university’s name be removed from this blog with which I complied, or the threats to go to the state medical board.

[Update: See Dan Carlat MD blog for followup to this post].

What are you so upset about? I told you I was Bi-Polar.

I’m not saying bipolar is a totally bs diagnosis. I am just saying it is way overdiagnosed.

Now it looks like I am going to have to become a candidate for Post-traumatic Embitterment Syndrome (Yes it too is being proposed as a new diagnosis at the APA, sigh) if the DSM Psychosis Work Group led by William Carpenter MD decides to move bipolar disorder into the psychotic disorders. I mean, there already is enough stigma associated with psychotic disorders. What are you going to do about the “bipolar II” people? Tell them they are psychotic too? And what about those four year olds with the bipolar diagnosis?”

Carpenter did say the shift would happen “over a few dead bodies” but that they “did want to get rid of schizoaffective disorder.”

Maybe the fact that Dr. Carpenter’s list of disclosures leads like a phone directory of the world’s drug companies might have something to do with this odd behavior. I mean, if it is a psychotic disorder, then people won’t quibble about giving antipsychotic drugs for it, right? Even if they do cause a 25% rate of akathisia.